5. Indications for surgical treatment of obesity and diabetes mellitus
This manual integrates the American Diabetes Association, the International Diabetes Federation, the Chinese Diabetes Association obesity and diabetes surgical treatment guidelines proposed obesity and diabetes surgical treatment indications, as follows.
(1) BMI ≥ 35kg/m2, whether or not combined with type 2 diabetes, is recommended to choose surgical treatment, and surgery is preferred for patients with combined diabetes.
(2) Patients with BMI ≥ 30 kg/m2 and type 2 diabetes mellitus, with lifestyle and pharmacological treatment difficult to control blood glucose or comorbidities, especially those with cardiovascular risk factors, are recommended to choose surgical treatment.
(3) Patients with BMI ≥ 27.5 kg/m2, combined with metabolic syndrome and poorly controlled diabetes, may opt for surgical treatment.
Contraindications
(1) Patients with drug abuse, alcohol addiction, patients with uncontrollable mental illness, and patients who lack the ability to understand the risks, benefits, and expected consequences of metabolic surgery.
(2) Patients with a definite diagnosis of type 1 diabetes.
(3) Patients with type 2 diabetes whose pancreatic islet beta-cell function has been largely lost. It is generally recommended that islet reserve function should be at least 1/2 of the lower limit of normal, and C-peptide should be ≥ 1/2 of the lower limit of normal.
(4) Those with contraindications to surgical procedures.
(5) Patients with diabetes mellitus with BMI <28 kg/m2 and satisfactory glycemic control with medication or insulin.
(6) Secondary obesity, gestational diabetes and other special types of diabetes are temporarily excluded from the scope of surgical treatment.
6.Surgical methods
Classification of surgical methods
At present, the clinical weight reduction and diabetes surgery surgical methods mainly include traditional weight loss surgery and some new surgical methods, this manual is unified named “gastrointestinal metabolic surgery (GIMS)”. Currently, GIMS should be performed through minimally invasive surgical procedures such as laparoscopy or endoscopy.
There are three main types of traditional bariatric surgery, which are.
(1) Restrictive procedures, such as adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG), which restrict gastric volume and cause a feeling of fullness at an earlier stage of eating.
(2) Malabsorbitive procedures, such as biliopancreatic diversion (BPD), which cause inadequate digestion of food and thus limit the absorption of nutrients.
(3) Mixed procedures, such as gastric bypass (GB), which combine the effects of the above two types of procedures.
The new weight reduction and diabetic surgeries currently carried out in the clinic mainly include sleeve gastrectomy (SG), SG combined with ileal interposition (IT), duodenal-jejunal bypass (DJB), intraluminal duodenal sleeve Endoluminal sleeve (ELS), etc.
International Gastrointestinal Metabolic Surgery Overview
In 2011, the total number of gastrointestinal metabolic surgeries performed worldwide exceeded 340,000, and the total number of surgeries performed in the Asia-Pacific region was about 23,000, with the main surgical procedures being RYGBP, SG, AGB, and BPD/DS, accounting for 46.6%, 27.8%, 17.8%, and 2.2% of the total number of surgeries, respectively. From 2003 to 2008 and then to 2011, RYGBP accounted for 65.1%, 49.0%, and 46.6% of the total surgical volume, SG accounted for 0, 5.3%, and 27.8%, and AGB accounted for 24.4%, 42.3%, and 17.8%, respectively.
RYGB and SG are currently the two most widely performed surgical procedures internationally, both worldwide and within the Asia-Pacific region. Among them, the proportion of SG in the total gastrointestinal metabolic surgery is showing a significant increasing trend. The number of surgeries is gradually decreasing due to more complications after AGB, the tendency of weight loss to rebound, and the poor treatment effect on diabetes.
This manual recommends surgical procedures
Roux-en-Y gastric bypass (RYGB) is the most commonly performed gastrointestinal metabolic surgery in the world, with a long-lasting effect on weight loss and an efficiency of 84% for obesity combined with diabetes. The results of the randomized controlled study showed that 1) SG can significantly improve T2DM in obese patients, and the effect is better than that of medical treatment. 2) There is no significant difference in the remission rate of T2DM between SG and RYGB, but the risk of postoperative complications is lower with SG than with RYGB.
In conclusion, this manual recommends Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) as surgical modalities for the treatment of obesity and diabetes mellitus.
Roux-en-Y gastric bypass (RYGB)
A small 15-30 ml gastric bursa is surgically created, completely separated from the distal stomach, with the entire duodenum and approximately 1000 px of proximal jejunum left open.
It is usually possible to lose 50kg, which is about 65-70% of the overweight portion of the body weight, and reduce the preoperative BMI by 35%.
The weight loss effect is remarkable, and it is currently the standard procedure for the treatment of obesity in Europe and the United States.
The radical cure rate of diabetes is 84%, and the efficiency rate is 95%.
It is the procedure of choice for patients with severe obesity with diabetes, hyperlipidemia, hypertension, and sleep apnea syndrome.
Sleeve gastrectomy (SG)
The large portion of the stomach is removed along the course of the lesser curvature of the stomach 2-150px up from the pylorus, supported by a balloon gastric tube, so that the remaining stomach becomes “sleeve”/”banana-shaped” with a volume of 60-100ml.
Reduction of 60% of the overweight portion
The rate of diabetes remission is similar to that of RYGB
The operation is relatively simple
Does not change the physiological state of the gastrointestinal tract, and is less likely to produce nutrient deficiencies
7.Pre-operative evaluation
(1) Medical history (history of obesity, history of diabetes, history of other coexisting diseases, history of obesity and complications of diabetes)
(2) Physical examination (weight, height, BMI, abdominal circumference, hip circumference, heart rate, blood pressure, etc.)
(3) Laboratory tests (blood glucose, glycosylated hemoglobin, insulin, C-peptide, liver and kidney function, blood lipids, thyroid function, sex hormones, insulin resistance, antibodies to type 1 diabetes)
(4) Physical examination (chest X-ray, body fat analysis, pulmonary function including arterial blood gas assessment, cardiac ultrasound, sleep apnea monitoring, etc.)
(5) Psychological assessment
(6) Smoking cessation, optimal glycemic control, treatment of dyslipidemia, discontinuation of estrogen therapy, cardiology consultation
(7) Education on the risks, benefits, and surgical modalities associated with gastrointestinal metabolic surgery
8.Post-operative follow-up
(1) Dietary guidance, gradual transition of liquid, semi-liquid and general diet, small and frequent meals, balanced meal plan, attention to extra-gastrointestinal nutrition for high-risk patients.
(2) Advise patients to increase physical activity
(3) Blood glucose control
(4) Weight loss effect assessment (BMI, body fat analysis)
(5) Diabetes (blood glucose, insulin, C-peptide, glycated hemoglobin)
(6) Effect of surgery on obesity and diabetes complications (metabolic syndrome, nephropathy, eye disease, etc.)
(7) Bone density testing
(8) Control of nutritional deficiencies (vitamin and mineral supplementation, oral ferrous sulfate, intravenous iron supplementation, etc.)
(9) Morbidity and mortality of complications associated with surgery
(10) Risks and benefits of surgery
9. Complication control
(1) Gastrointestinal complications
Anastomotic leak
Bleeding
Pulmonary infection, pulmonary infarction
Deep vein thrombosis
Gastroesophageal reflux
Anastomotic ulceration
Anastomotic stenosis
Blind collaterals syndrome
Internal hernia
(2) Nutritional complications
Rapid protein loss
Anemia
Micronutrient deficiency
Osteoporosis